e-Consult 2022 | The Office of Dr. Josh Hamilton APRN LLC Question Title * 1. Patient Information Patient's name * Person completing this form Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address * Phone Number * Question Title * 2. Rate your MOOD for the past two weeks: Sad - Depressed "Normal" Too Happy - Manic Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 3. Rate your ANXIETY LEVEL for the past two weeks: None Moderate Panic Attacks Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 4. Tell us about your SLEEP pattern for the past week: Taking too long to fall asleep Waking up in the middle of the night Waking up too early in the morning Nightmares Vivid dreams More information about my SLEEP PATTERN: Question Title * 5. Since your last appointment, has your WEIGHT: Increased Stayed the same Decreased Tell us about your APPETITE for the past two weeks: Question Title * 6. Have you taken your MEDICATIONS as prescribed? Yes No Question Title * 7. Are you experiencing any MEDICATION SIDE-EFFECTS? Yes No What side-effects are you experiencing? Question Title * 8. Do you think your MEDICATION needs to be ADJUSTED or CHANGED? No Yes If yes, please describe your concerns here: Question Title * 9. Are you participating in COUNSELING or THERAPY? Yes No If so, please list therapist and frequency of sessions: Question Title * 10. Have there been any CHANGES in your OVERALL HEALTH? No changes I have seen my family doctor/specialist I have started/stopped a medication I have been treated at urgent care/ER I have had the cold/flu I have had other health problems since last appointment Please describe changes in your health, including medications you've started/stopped, medical visits you've had, etc. Done